(03HDC02435, 26 August 2004)

A man working as a stockman for a
regional food-processing company complained that an occupational
health nurse and a general practitioner did not adequately assess
injuries to his leg and refer him appropriately, or give him
adequate information about his condition.

The man initially attended the company's health centre on the site
of the meat works. He completed an accident register form reporting
minor bruising to his right lower leg after a "knock" from a sheep
the previous evening. He was assessed by a registered nurse, who
recorded in the day book (but not his medical file) that he had
been bitten in the left leg by a sheep and had a headache; his skin
was not broken and there was no bruising. The man was given Panadol
and had the next two days off work.

The following day he attended the medical centre again, but it was
closed for a public holiday. He recorded in an accident register
form that he had been hit on the leg that morning and had bruising.
He did not consult one of the first aiders available when the
centre was closed, or consult his GP or an after-hours medical
centre. He returned to the company medical centre the next morning,
and a first aider recorded on an accident register form that the
previous day he had been hit by a sheep and sustained moderate
bruising on his right lower leg, and it was slightly swollen,
bruised and painful. The man was referred to the health and safety
manager, an occupational health nurse who was consulted by first
aiders on occupational health matters, although this was not in her
employment contract. She observed that he had localised swelling
but a good range of movement and was able to walk. Arnica cream was
applied to the bruise, and the man was given a Voltaren tablet and
a support bandage for his leg. She advised him to return in the
afternoon or earlier for review; he did visit the medical centre
but it was unattended at the time and he was not seen. He did not
contact the occupational health nurse or the first aider, who were
elsewhere on the site at the time. Signs explaining how to do so
were evident at the medical centre, and employees were routinely
advised of the procedure at their induction.

The man returned to the medical centre the following morning. The
first aider noted increased swelling overnight and referred him to
the occupational health nurse, who decided to refer him to the
centre's GP. The GP recorded that the man's leg was very swollen
and bruised, but he walked unaided with a slight limp; there was no
evidence of abnormality in the knee and ankle, nor of a fracture.
The GP did not take the man's temperature, as he did not appear
unwell, toxic or feverish, and the skin did not appear broken or
blistered. The GP recommended three days in bed with the leg
elevated, and reassessment within the three days if needed. The man
visited family and then returned home, where he wrapped a towel
around his leg because it had started to weep, and went to bed. His
wife found him semi-conscious the next morning and took him to a
local medical centre, where he was found to have an infection in
his lower leg and cellulitis in his foot. His temperature was
slightly elevated and he was referred to hospital. He was initially
treated with intravenous antibiotics, but the skin became necrotic,
necessitating surgical debridement, and an abscess developed and
required draining. He was discharged from hospital three weeks
later.

It was held that the occupational health nurse did not breach the
Code. She properly assessed and treated the man's leg and
appropriately told him to return for review later in the day; at
the time there was no clinical evidence of an infection and his
condition did not warrant referral. She also promptly arranged for
him to be assessed by the GP the following day when the swelling
had increased, and provided adequate information to the GP.

The GP was also held not to have breached the Code in the care he
provided and the information he gave to the man. At the time of the
consultation there was no clinical evidence of infection or reason
to suspect infection might occur; the infection developed very
quickly and was not detectable until after the man's consultation
with the GP. The man had been advised to return for reassessment if
he was concerned about his condition.

The need for comprehensive documentation of workplace injuries and
interventions was commented on, and it was recommended that the
food-processing company clarify the role and responsibilities of
the occupational health nurse.